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Orofacial Myofunctional Dysfunction Referral Form

Date

Patient Name

Age

Parent

Email

Phone

Referred By

Phone

Main Concern

SYMPTOMS

MOUTH BREATHING

LIPS OPEN AT REST

POOR TONGUE REST POSTURE

TONGUE THRUST SWALLOWING

EATING DIFFICULTIES/GAGGING

DROOLING

SHORT LINGUAL FRENUM

SHORT LABIAL FRENUM

SNORING

CLENCHING/GRINDING

FACIAL PAIN/HEADACHES

THUMB SUCKING/ SUCKING HABIT

Thank you for submitting!

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